West Virginia Code of State Rules
Agency 65 - Health Care Authority
Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY
Series 65-05 - Hospital Cost-Based Rate Review System
Section 65-5-22 - Approval of Discount Contracts
Universal Citation: 65 WV Code of State Rules 65-5-22
Current through Register Vol. XLI, No. 13, March 29, 2024
22.1. Pursuant to W. Va. Code '16-29D-20, no contract for the payment of patient car services between a purchaser or third-party payor and a hospital which establishes discounts to the purchaser or third-party payor shall take effect until it is approved by the board. To obtain approval by the board, a hospital must file with the Authority an executed copy of the proposed contract with its rate application at least forty-five (45) days prior to the beginning of its fiscal year and as further described in subsection 6.2 of this rule.
22.2. Discount contracts may be filed with the Authority for temporary approval subject to retroactive review outside of the time period described in subsection 22.1 of this rule only under the following conditions:
22.2.1. The hospital is
a border hospital that meets the criteria and follows the procedure in
legislative rule, "Temporary Approval of Discount Contracts for Border
Hospitals," W. Va. C.S.R. '65-22-1 et seq., or
22.2.2.a. The hospital has negotiated a
discount contract with a new entity and said negotiations could not have been
completed and the executed contract filed with the Authority within the time
frame specified in subsection 6.2 of this rule. For purposes of this subsection
"new entity" is defined as a purchaser or third-party payor which has not
previously executed a contract for the payment of patient care services with
the hospital. Temporary approval is not available for a contract with a
third-party payor or purchaser which has previously executed or is currently a
party to a contract for the payment of patient care services with the
hospital.
22.2.2.b. In order for a
hospital to obtain temporary approval of a discount contract the hospital shall
file a verified notice with the Authority, which shall be filed at least five
(5) days in advance of the date upon which the proposed discount contract is to
be considered temporarily approved and shall:
22.2.2.b.1. Identify the hospital.
22.2.2.b.2. State affirmatively that the
discount contract is with a new entity as defined in subsection 22.2.2.a of
this rule and identify the new entity.
22.2.2.b.3. State affirmatively that the
hospital would be at risk to lose a significant portion of patients to other
hospitals if the discount contract is not temporarily approved.
22.2.2.b.4. Identify the other hospital or
hospitals.
22.2.2.b.5. State
affirmatively the facts and circumstances which prevented the hospital and new
entity from executing a contract and submitting it with the hospital's rate
application.
22.2.2.b.6. State
affirmatively that the discount shall not decrease the charges for the services
below the actual cost to the hospital.
22.2.2.b.7. State affirmatively that the cost
of the discount shall not be shifted to any other purchaser or third-party
payor.
22.2.2.b.8. State
affirmatively that the discount shall not result in a decrease in the
hospital's proportion of medicare, medicaid, or uncompensated care
patients.
22.2.2.b.9. State
affirmatively that the discount is based on criteria which constitute a
quantifiable economic benefit of the hospital.
22.2.2.b.10. Include a copy of the discount
contract.
22.2.2.b.11. Present such
other and further information or documents as may be requested by the
Authority.
22.2.2.c
22.2.2.c.1. Following receipt of a verified
notice complying with the requirements of this subsection, the Authority shall
for the purpose of retroactive review determine within fifteen (15) days
thereafter whether or not the verified notice is complete. If the verified
notice is not determined complete, the Authority may request additional
information from the hospital. Upon receipt of the additional information from
the hospital, the Authority again has fifteen (15) days within which to
determine whether or not the verified notice is complete.
22.2.2.c.2. Upon determining that the
verified notice is complete, the Authority shall publish a notice of the
determination of completeness and/or temporary approval of the discount
contract, as may be appropriate, in the Saturday Charleston newspapers and the
State Register and shall retroactively review the proposed discount contract
with the hospital's next succeeding rate application in order to determine
whether the discount contract meets all of the requirements for final approval
set forth in W. Va. Code '16-29B-20.
22.2.2.c.3. Upon obtaining temporary approval
of any proposed discount contract, the contract is further subject to
retroactive review by the Authority in accordance with the criteria set forth
in W. Va. Code '16-29B-20
and the rate review procedures set forth in W. Va. Code '16-29B-21.
22.2.2.c.4. The effective date of any
temporary approval is the date which is five (5) days from the date of filing
of a verified notice meeting the requirements of subsection 22.2.2.b of this
rule or the date the Authority determines the verified notice is complete,
whichever first occurs.
22.2.2.c.5.
In the event that the Authority determines that the discount contract does not
meet all of the requirements for temporary approval set forth in this
subsection, subsequent to a temporary approval of the contract, the Authority
may issue an order denying and revoking the temporary approval of the discount
contract at any time after such temporary approval. The order is effective as
of a date established by the Authority in the order. The effective date shall
not be less than ten (10) days from the date of the order and which effective
date may exceed ten (10) days from the date of said order in the discretion of
the Authority upon good cause shown for the extension.
22.2.2.c.6. In the event that the Authority
determines during retroactive review in accordance with this section that the
discount contract meets the standards for final approval of discount contracts
set forth in W. Va. Code '16-29B-20, the
Authority shall issue a final order approving the discount contract in
accordance with the procedures for rate review set forth in W. Va. Code
'16-29B-21.
22.2.2.c.7. In the event that the Authority
determines that the discount contract does not meet the standards for final
approval of discount contracts set forth in W. Va. Code '16-29B-20, the
Authority shall issue a final order denying approval of the discount contract
and rescinding the previous temporary approval in accordance with the
procedures for rate review set forth in W. Va. Code '16-29B-21.
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